Medicare Compliance & Reimbursement

Get the facts to boost your excision reimbursement

When your physician performs lesion excisions, don't forget that you may be able to access the musculoskeletal (20000-series) codes, or you could seriously undercut your reimbursement for these procedures.

When you report an excision procedure, such as a lipoma (fatty tumor) removal, consider reporting either the codes for benign lesion excision (11400-11471) or the codes for musculoskeletal soft-tissue excision.

Your code choice depends on the excision's depth and, just as important, the specificity of the physician's documentation, says Jeffrey Weinberg, MD, director of the Clinical Research Center, Department of Dermatology, at St. Luke's-Roosevelt Hospital Center in New York City.

Depth Provides a Guide for Best Excision Code

Guideline: If the physician's incision does not go deeper than the fascia, the conservative choice is the appropriate code from CPT's "Integumentary System" section 11400-11471, although the excision needn't necessarily reach the fascia to qualify as a musculoskeletal procedure in all cases.

Example: If the physician's documentation specifies, "Full-thickness excision of 2.5-cm lesion (with margins) from left shoulder with simple closure," the appropriate code choice is 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm).

In this case, both the term "full-thickness" (that is, "through the dermis") and "simple closure" should tip you off that the required incision was not very deep.

"During 'full-thickness' excisions, the surgeon removes all layers of skin, and possibly even some subcutaneous tissue, but this does not mean that you should select a musculoskeletal code," says Terri Brame, CPC, CPC-H, principal at BEST Coders. "The excision doesn't extend into the musculoskeletal soft tissues, it just extends to them."

Incision Isn't Always Only Skin-Deep

If the excision goes deeper than the fascia, the removal is definitely not superficial, and the musculoskeletal codes are more appropriate, Weinberg says.

Important: Your physician's documentation must be explicit to support using these codes and should specifically note the incision's depth.

Example 1: If the physician's documentation notes a subcutaneous tumor, you may report 23075 (Excision, soft-tissue tumor, shoulder area; subcutaneous) for removal of lipoma (fatty tumor). This code will pay you about $190.

For even deeper incisions (subfascial or intramuscular), you may choose 23076 (Excision, soft-tissue tumor, shoulder area; deep, subfascial, or intramuscular), which reimburses almost $550, Weinberg says.

Helpful tip: If your physicians often forget about the musculoskeletal codes, you can help them remember by including a list of the codes according to anatomic area on your encounter form to jog their memory, says Patricia Tinker, CPC, clinical practice manager in the department of dermatology at Yale University School of Medicine in New Haven, CT.

Example 2: The physician notes that she excised a subcutaneous tumor from the patient's neck. In this instance, [...]